Pain is not a “thing”

I’m reading some fascinating books at the moment. I’m such a pain geek I take pain books away with me on holiday! Anyway, the two books to hit me between the eyeballs recently are The Pain Chronicles by Melanie Thernstrom (published 2010), and The Story of Pain by Joanna Bourke (published 2014). What makes both of these books fascinating is that these both look at the history of pain and pain management, and explore the “what it is like” to be in pain. Reading them, I’m forcefully reminded that the ways in which we conceptualise pain is an incredibly social process. Social in that while we have discovered much about the neurobiology underpinning our experience of pain in the last 40 years or so, the ways in which we understand pain as it is experienced (and pain is always an experience) depend on prevailing attitudes towards suffering.

I’ve written before that pain and suffering are not the same thing. I’ve also pointed out that the language we use is one way to convey the “what it is like” to have pain, and so expressions like “cutting, burning pain” or “stabbing pain” or “grinding pain” are metaphoric descriptions that use visual imagery possibly to elicit activation of mirror neurones so that the listener can begin to experience the “what it is like” to have pain.

The reason this is important when we talk about pain and pain behaviour is that the things we do when we’re sore are framed within our own culture, and reflect what we know and understand about what-it-is-like to be experiencing pain. This changes over time, and Joanna Bourke gives excerpts from two different editions of the same textbook:

The jolting of a carriage is insupportable to him… As the evil increased, micturition becomes more and more frequent and distressing; the pain following the act is very severe – patients writhe with their bodies, and grind their teeth in agony (1852 edition)

The jolting of a carriage increases his symptoms… As the stone increases in size, micturition becomes more frequent and distressing, and the pain or uneasiness at the end of the penis becomes more constant and severe (1881 edition)

Bourke points out that earlier editions focus more on the suffering of the patient, as opposed to the increase of “symptoms”, the “evil” becomes “the stone”, and “the act” of micturition is turned into “pain in the penis”. The pain itself is even downgraded to “pain or uneasiness”, Furthermore, patients no longer “writhe with their bodies and grind their teeth in agony”, but penises simply hurt more (p.86). Pain, over time, and within our socio-cultural heritage, has moved from being readily acknowledged as distressing, an evil, and agonising (all very emotive words), to a far less emotive process of a “stone” and “uneasiness” at the end of the penis.

Our responses to other people who express their pain is also shaped by social processes. Here’s another excerpt from Bourke’s book in which a physician was attending “a spoiled…society woman” who was “accustomed to enjoy to the full the pleasures of life” and developed heart pain. The doctor says “My lady, you are suffering from a pain which you are right in supposing is due to your heart. I might give you something which would relieve the pain, but I don’t propose to do so. The pain is a warning to you to curtail your activities and live a different life.” (p. 128) So much for sympathy! This was the 1930’s.

In times when life was short, hard and often painful, and people lived close to one another, were exhorted to be mindful of their afterlife (because this, it was promised, would be far better than their current life – if, and only if, they were pious and quietly accepted their suffering as a gift from God, sent to test them, or to punish them). Even children were advised to remember that God gave pain, therefore they should ask for “grace to submit to his will”, continue with their chores without complaining, and “draw strength from the ‘Ominpotent arm’ of Christ, anticipating future bliss in paradise.”

I think we’re inclined to forget that how we demonstrate to others that we are hurting is intimately connected to social processes we’ve been immersed in since birth. This is why the paper “Impact of pain behaviors on evaluations of warmth and competence” is a very good one, impeccably carried out with wonderful experimental design, but must still be seen in our current social context. The study examined individual’s interpretations of pain behaviours, using a wireframe animation (generated by computer but based on an individual firstly walking normally, then walking with evident pain behaviour). The observers indicated that the recording of the individual walking with pain behaviours was more depressed, less fit, and not as competent as the recording of the individual walking normally. This suggests that when people observe individuals demonstrating pain behaviours, even without any other cues, our social impression is that they are less competent and we are more likely to withdraw from them – or, and I’m extrapolating a bit here, if we’re in the business of helping people, we may believe they are especially vulnerable and need our help.

However: in our society, bombarded as we are with advertisements for a pain-free existence, putting forward the notion that we should never have to experience pain, I think this study shows us very clearly what-it-is-like to be socially rejected on the basis of not being “perfect”. I wonder what the results would have been if it could have been carried out in the 1880’s.

I wonder too, when we’ll begin to look at health providers levels of empathy and catastrophising (Thanks to Lisa for this idea!). If we’re inclined to be highly empathic, perhaps to the point of unhelpfully over-identifying with our patient’s suffering (where we become distressed because our patients are distressed), and if we also catastrophise or think the worst, I think we’ll over-interpret the pain behaviour of others and attempt to compensate by treating the person so that our own distress is reduced. And because this is a social process, and we’re probably not aware of it even occurring, perhaps we’ll be completely oblivious to the adverse effects of doing so. I’d love to see the study carried out by Ashton-James and colleagues repeated in a sample of health professionals – that would be very interesting indeed.

4 comments

Of course, I agree with you that pain cannot be a concrete “thing”. But this this message does not seem to have been grasped by many who are high up in the pain world, who have attempted to reify(chronic) pain as a disease entity.

Negempathy is exactly the term! I really want to come to grips with the mechanisms behind people who keep on treating (unsuccessfully) chronic pain with short term results, but no longer-term reduced disability. Not sure if this is the main mechanism, but it seems plausible that a clinician who catastrophises, and is high in empathy would respond more strongly to a distressed person than a clinician with clearer personal boundaries (less empathy) and who doesn’t catastrophise. I understand the rationale behind the call for chronic pain to be classified as a disease entity, but I agree (now!) that it’s not the right term. We would need to coin another name to represent the disease that underpins the experience of ongoing pain. I believe Clifford Woolf is responding to this in a soon-to-be-published paper in Pain.

Quite a challenge! There may be a number of recognised diseases that can underpin such an experience. But those who believe that chronic pain can be a disease-in-itself have failed to come up with a suitable name for this “new” disease. Perhaps Clifford Woolf will enlighten us.

I just recently learned a little bit about pain; both physical and emotional. I find it interesting that we describe a certain pain to someone by using metaphoric descriptions such as cutting, burning and stabbing pain. I believe that we do this so it is easier for someone else to imagine what our pain feels like.

You make an interesting point with the study about pain being related to social processes we have been immersed in since birth. I agree that this study clearly shows what it is like to be socially rejected for not being perfect. I do not think that a person in pain should be stereotyped as someone who is less competent, more depressed, less fit, etc. Based on my knowledge of health and medicine, there are a wide variety of ways in which we feel pain and anyone is inclined to feel pain. I too would love to see the results of this study if it were carried out a long time ago. I wonder how the results would vary; perhaps people would have been more sympathetic to individuals in pain.

If the people in this study knew that they were being judged as incompetent by others, I’m sure their feelings would be hurt. I have recently learned that “hurt feelings” are really like physical pain. When someone feels rejected by others, activity increases in the anterior cingulated gyrus, just as it does for physical pain. I also learned that you can actually relieve hurt feelings by taking acetaminophen.